Self-Dosing Pain Medication Errors Too Common: Study

December 7, 2008

FRIDAY, Dec. 5 (HealthDay News) — Allowing patients to control their own pain medication intravenously is four times more likely to cause the patient harm than other medications, a new study says.

The report, published in the December issue of The Joint Commission Journal on Quality and Patient Safety, shows that most mistakes involving intravenous patient-controlled analgesia (PCA) resulted from either human error, equipment issues or communication problems that led to the patient receiving the wrong dosage or drug. PCA errors also tended to be more severe — harming patients and requiring clinical interventions — than other types of medication errors.

“The entire PCA process is highly complex,” lead author Rodney W. Hicks, the UMC Health System Endowed Chair for Patient Safety at Texas Tech University Health Sciences Center in Lubbock, said in a news release issued by the journal’s publisher. “PCA orders must be written, reviewed, and then accurately programmed into sophisticated delivery devices for patients to be pain free. Such complexity makes PCA an error-prone process. Health care organizations should now plan to make the process safer.”

The five-year study uncovered more than 9,500 PCA errors. Patients were harmed in 6.5 percent of these incidents, compared to 1.5 percent for general medication errors.

In PCA, a computerized pump with a syringe of prescribed pain medication is hooked straight into a patient’s intravenous (IV) line. The patient can self-dose by pushing a button.

Hicks and his co-authors make three recommendations to reduce future PCA errors:

Simplify the equipment. Easier step-by-step setup instructions could cut down on programming errors by caregivers setting up the PCA machine’s dosage levels.
Use bar codes and keep an electronic medication administration record. Making a standard practice out of independent double-checks of the PCA orders, the product, and the PCA device could help prevent giving patients’ the wrong medication.
Design and use easy, standardized forms for PCA. Use of universal forms by pharmacists could correct communication issues in the process.

More information

The American Pain Foundation has more about pain management.